Healthcare Provider Details

I. General information

NPI: 1114966041
Provider Name (Legal Business Name): INSTITUTE ON BEREAVEMENT & LIFE TRANSITION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 SE SHILOH DR
LEES SUMMIT MO
64063-1036
US

IV. Provider business mailing address

549 SE SHILOH DR
LEES SUMMIT MO
64063-1036
US

V. Phone/Fax

Practice location:
  • Phone: 816-419-3146
  • Fax: 816-525-3416
Mailing address:
  • Phone: 816-419-3146
  • Fax: 816-525-3416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2000159892
License Number StateMO

VIII. Authorized Official

Name: DR. PAIGE STANFIELD-MYERS
Title or Position: CLINICAL DIRECTOR
Credential: PHD, LPC
Phone: 816-419-3146